Of goldilocks and neonatal hypernatremia

A heart-wrenching story has been circulating on social media about an exclusively breastfed baby who suffered brain damage after 4 days of ineffective feeding. The mother,  Dr. Christie del Castillo-Heygi, is a physician, and she shares how she was reassured that all mothers can make milk, and did not realize until she engaged a lactation consultant at 96 hours postpartum that her child was profoundly dehydrated.

It’s a tragic story. Dr. del Castillo-Heygi is petitioning public health leaders to warn all parents about the risk of irreversible brain damage with exclusive breastfeeding. That warning would directly challenge efforts across the US, and around the world, to emphasize the value of exclusive breastfeeding and the risks of unnecessary supplemental feeding. This push for exclusive breastfeeding is part of efforts to implement the Baby Friendly Hospital Initiative, a set of quality improvement efforts that increase the likelihood that women achieve their personal breastfeeding goals. For healthy infants, supplementation can interrupt the demand-drives-supply physiology of breastfeeding, reduce a mother’s milk supply, confuse baby’s latch, and expose the infant’s gut to allergens that may impact lifelong health.

So who’s right? Well, it’s complicated – and my sense is that this debate reflects the challenges of ensuring that families have the knowledge and support they need to initiate and sustain breastfeeding in the early weeks after birth.

We might start by acknowledging, once and for all, that not all mother-baby dyads are able to breastfeed exclusively. Reproductive physiology is not infallible. 10.9% of women have difficulty getting pregnant or carrying a baby to term. 15 to 20% of pregnancies end in miscarriage, 10% of infants are born preterm, and 1 in 100 infants are stillborn. Similarly, less than 100% of women can exclusively breastfeed.

That’s why the American Academy of Pediatrics recommends that all breastfed newborns be monitored for weight loss, and all breastfed babies be seen for a weight check at 3 to 5 days of life. Several UK studies have found that routine weight checks at 2-3, 5 and 10 days of life identify babies at risk and reduce the severity of dehydration. We need to hold health systems accountable for ensuring that these visits happen, whether in outpatient clinics, through home visits, or in newborn follow-up centers at maternity hospitals.

Primary lactation failure is real, and if it is unrecognized, it can lead to adverse outcomes. An emphasis on exclusive lactation without adherence to recommended post-discharge follow-up in the community is a set up for bad outcomes.

How often do those outcomes happen? Several studies have tried to measure how frequently exclusively breastfed babies get into trouble from insufficient milk transfer. Severe hypernatremia, defined as a sodium > 160 mEq/L, appears to be quite rare: A UK population-based study measured rates of severe hypernatremia among newborns, and found that 7 babies per 100,000 were affected. None of the 62 infants with severe hypernatremia had long-term complications. More moderate sodium elevations, to levels higher than 150 mEq/L, occur in between .03% and 2.77% of infants (see Table); combining reports in the published literature from the UK, Italy and Switzerland , 1 in 1000 healthy babies is affected. The major exceptions were two studies conducted in Turkey. In the more alarming study, 14% of babies developed an elevated sodium level; of note, mothers and babies were routinely sent home within 24 hours of birth, well before breastfeeding could be established.

Excessive weight loss, defined in one prospective study at >10% of birth weight by day 3 in conjunction with the mother not feeling that her breasts were fuller by 72 hours, is far more common, affecting 19% of women in a cohort of first-time mothers. If one in five babies experience excessive weight loss, then those of us providing breastfeeding education and support need to choose our words carefully. Statements like “all mothers can make enough milk for their babies,” like, “All mothers can birth vaginally,” sound empowering, but they are not true. We have to watch our language. Just as there is an appropriate c-section rate, there is an appropriate supplementation rate. We’re not aiming for 100% exclusive breastfeeding. We are aiming for using supplementation judiciously, when indicated.

With that in mind, we need to be thoughtful when we share information about the side-effects of supplementation. Teaching that “just one bottle” alters baby’s gut for weeks can be a powerful deterrent, dissuading a family from supplementing a thriving baby, but those same warnings, rigidly adhered to, can lead a mother to keep offering the breast to a baby who’s struggling because “formula is bad.” Perhaps we need to talk about formula the way we talk about antibiotics. For a bacterial pneumonia, antibiotics can be life saving; for the common cold, they can give you a nasty yeast infection, without any relief from the coughing and sneezing. Such thoughtful guidance becomes particularly important for dyads at high risk of delayed onset of lactogenesis.

This is especially tricky in the face of relentless marketing of infant formula. Free samples, seductive advertising campaigns, and pseudo-empowerment messaging to mothers muddy the waters and make it incredibly complicated to parse “medically indicated supplementation” from “formula-marketing-driven supplementation.”

We also know that breastfeeding is a confidence game – pain and anxiety reduce milk let down, and a barrage of test weights and warning sign tutorials could derail normal feeding for a substantial proportion of women. We need to develop tools for counseling families that strike a balance between reassurance and vigilance for adequate infant intake in the first few days after discharge. Too much counting of diapers and poops could lead to excessive supplementation; too much “all moms can do it!” messaging could blind families to signs that baby is in trouble.

We also need to find ways to identify at-risk kids before discharge, ideally for home-visit follow-up. Several authors have identified risk factors, including first-time mothers, birth by c-section, and breastfeeding problems in the hospital, that could be used to prioritize who is at risk. The Academy of Breastfeeding Medicine has a page-long list of risk factors. The ideal might be an electronic-medical-record-generated “Red, yellow, green” feeding assessment that would identify at-risk babies based on mom and baby history, gestational age, birthweight, weight trajectory in hospital, and feedings observed by a qualified lactation professional. “Red zone” babies would get discharge teaching that emphasized vigilance, and green-zone babies would get discharge teaching that emphasized reassurance. Researcher Valerie Flahermann has done formative work in this area with her NEWT nomogram, which provides hour-by-hour guidelines for infant weight loss for infants born vaginally or by c-section. What’s not known is how to best incorporate this tool into practice and share the information with families, so that we strike that balance between vigilance and reassurance.

My sense is that every day, experienced, thoughtful pediatric providers are routinely making clinical judgements about which kids are at risk and need close follow-up. As hospitals adjust their practices to support exclusive breastfeeding, we need to figure out how to share this “Spidey-sense” with providers who have trained and practiced in settings where formula use was the norm.

What, then, of the tragic stories of brain-damaged babies? Wouldn’t it be easier to supplement all babies, rather than redesign our systems of care to identify dyads at risk and ensure early follow-up for every baby?

It’s here that we have to think about numbers needed to treat, and numbers needed to harm. If we go with the estimate that 1 in 1000 babies develop an elevated sodium level, we would have to supplement 1000 healthy kids to avert one case of hypernatremia. If we use the UK numbers for severe hypernatremia, we’re looking at 100,000/7, or 14,285 healthy babies being supplemented, to prevent one affected baby. Multiple pediatric health conditions, including ear infections, hospital admissions for lower respiratory tract infections, gastrointestinal illness, and sudden infant death syndrome, are more common in infants who are not breastfed exclusively. How many cases of these conditions might we cause with routine supplementation to prevent a hospitalization for hypernatremia?

Given these unknowns, it seems prudent to instead reevaluate the way we deliver care to ensure the safety of dyads at risk, while simultaneously supporting dyads who are succeeding. We need to hear from families who have experienced these tragic events to identify the gaps that prevented them from getting recommended care, and we need to develop a multifaceted approach that’s neither too vigilant nor too reassuring. Like Goldilocks, we need an approach for each family that is just right.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

This post was updated on 2/1/2016 to include Dr. Christie del Castillo-Heygi’s name and a link to her story. She writes:

My son was born 8 pounds and 11 ounces and had lost 1 pound 5 ounces at day 3 of life, about 15% from birth weight. At the time, we were not aware of and were not told the percentage lost, and having been up all night long trying to feed a hungry baby, we were too exhausted to figure out that this was an incredible amount of weight loss. Our pediatrician told us that we had the option of either feeding formula or waiting for my milk to come in at day 4 or 5 of life. (Emphasis mine.)

As noted in my comment below, it is troubling that a 15% weight loss was documented by a pediatrician without an immediate evaluation of feeding or recommendation for supplementation.  

Table: Studies of Neonatal Hypernatremia

Study	Affected infants	Study sample	% of infants with sodium > 149 mEg/L
Manganaro 2001	19	686	2.77%
Oddie 2001	8	32,015	0.03%
Laing 2002	13	9000	0.14%
Iyer 2008	60	96,000	0.06%
Konetzny 2009	18	2788	0.65%
Kudumula 2009	22	6595	0.33%
Total	140	147,084	0.1%

References

Iyer NP, Srinivasan R, Evans K, Ward L, Cheung WY and Matthes JW (2008). “Impact of an early weighing policy on neonatal hypernatraemic dehydration and breast feeding.” Arch Dis Child 93(4): 297-9.

Konetzny G, Bucher HU and Arlettaz R (2009). “Prevention of hypernatraemic dehydration in breastfed newborn infants by daily weighing.” Eur J Pediatr 168(7): 815-8.

Kudumula V, Asokkumar A, Akinsoji O and Babu S (2009). “Breastfeeding malnutrition in neonates: a step towards controlling the problem.” Arch Dis Child 94(3): 246.

Laing IA and Wong CM (2002). “Hypernatraemia in the first few days: is the incidence rising?” Arch Dis Child Fetal Neonatal Ed 87(3): F158-62.

Manganaro R, Mami C, Marrone T, Marseglia L and Gemelli M (2001). “Incidence of dehydration and hypernatremia in exclusively breast-fed infants.” J Pediatr 139(5): 673-5.

Oddie S, Richmond S and Coulthard M (2001). “Hypernatraemic dehydration and breast feeding: a population study.” Arch Dis Child 85(4): 318-20.